Wellfleet Recreation Summer Registration 2018
Child's Last Name *
Your answer
Child's First name *
Your answer
Gender *
PAYMENT SHOULD BE MADE BY SENDING A CHECK TO: WELLFLEET RECREATION DEPARTMENT, 300 Main St., Wellfleet, MA 02667. Checks should be made out to: Town of Wellfleet. Payment may also be made in person on the Monday your child begins participating, at the Baker's Field Recreation Building, 70 Kendrick Ave. Wellfleet, MA PLEASE NOTE CHILD(S) NAME(S) ON CHECK. PROGRAMS RUN FROM JULY 2 - AUGUST 17, 2018
Date of Birth *
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Age of Participant
Your answer
Address 1 *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent/Guardian Name
Your answer
Parent/Guardian Phone Number *
Your answer
E-mail Address *
Your answer
Residence Status *
Relationship to property owner *
Wellfleet Street Address (if different from above) *
Your answer
Emergency Contact #1 Name *
Your answer
Emergency Contact #1 Phone Number *
Your answer
Emergency Contact #2 Name *
Your answer
Emergency Contact #2 Phone Number *
Your answer
Emergency Contact #3 Name
Your answer
Emergency Contact #3 Phone Number
Your answer
Person(s) other than parent/guardian authorized to pick up your child *
Your answer
Does your child have any illness or handicap that would hinder participation? *
If yes, please explain
Your answer
Do you give Wellfleet Recreation permission to apply sunscreen to your child? *
Do you give Wellfleet Recreation permission to apply bug spray to your child? *
Do you give Wellfleet Recreation permission to photograph your child? *
Do you give your child permission to participate in the summer lunch program? *
Through Project Bread/Food for Kids we are provided with a balanced, nutritious and peanut free snack and lunch for the children in the program.
Does your child have any food or dietary restrictions?
If yes, please provide details below:
Your answer
Does your child have any Allergies?
If yes, please provide details below:
Your answer
Is there anything else you think we should know about your child?
Your answer
Summer programs offerred by Wellfleet Recreation *
**proof of residency is required for discounted rates**
Required
Weeks Participating
Red Cross Swim Level
If signing up for swim lessons
Agree to Terms *
By signing this permission form for my child to participate in the Wellfleet Recreation Summer Program, I agree to the following: I understand that Wellfleet Recreation has the right to suspend or expel the participant from the program if, at any time, the participant's involvement jeopardizes the safety (emotional or physical) of other participants, staff, or volunteers. All fees collected by Wellfleet Recreation are NON-REFUNDABLE. Wellfleet Recreation is not responsible for children before the designated drop- off time and after the designated pick-up time. I agree to have my child picked up immediately in the event of being summoned by staff for reasons including, but not limited to, emotional or behavioral issues, illness, injury, or severe weather situations. I give permission for my child to receive medical treatment in the event of injury while participating in the program. I authorize staff at Wellfleet Recreation who are trained in the basics of first aid to give my child first aid when appropriate. I understand that every effort will be made to contact me in the event of an emergency requiring medical attention for my child. However, if I cannot be reached, I hereby authorize the program to transport my child to the nearest medical care facility. I have noted if my child's image CANNOT be used in promotional materials for Wellfleet Recreation or its collaborators. No indication means that my child's image CAN be used in promotional materials for the Recreation Department. I, the parent / guardian of the minor child being registered, hereby consent to the child's participation in the Summer Recreation program conducted, supervised, sponsored, or otherwise controlled by the Town of Wellfleet and the Wellfleet Recreation Department for the duration of the Program. In consideration of the Town admitting the child to this program or event, I agree on behalf of the child and myself to release the Town and Department, and their respective officers, employees (including volunteer staff) and agents from and against all liability, loss, damage, costs, and claims which may arise by reason of personal injury or property damage arising from the child's participation in the Summer Recreation program, and I also agree to indemnify and hold harmless the Town and Department and their respective officers and employees (including volunteer staff) and agents from and against all liability, loss, damage, and costs that the Town or Department may incur by reason of claims for personal injury or property damage arising from the child's participation in the Summer Recreation program. "Participation" is deemed to include daily program activities, field trips, and transportation to and from the same. I further affirm that I have read and understand the contents of this form. I understand that my child's participation in the Summer Recreation programs is voluntary and that my child and I are free to choose not to participate in said programs.
PAYMENT SHOULD BE MADE BY SENDING A CHECK TO: WELLFLEET RECREATION DEPARTMENT, 300 Main St., Wellfleet, MA 02667. Checks should be made out to: Town of Wellfleet. Payment may also be made in person on the Monday your child begins participating, at the Baker's Field Recreation Building, 70 Kendrick Ave. Wellfleet, MA PLEASE NOTE CHILD(S) NAME(S) ON CHECK.
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